Tips to avoid stigmatizing language

[G Sheb]

Can't resist, from the healthit.gov FAQs:

"
It would likely be considered an interference for purposes of information blocking if a health care provider established an organizational policy that, for example, imposed delays on the release of lab results for any period of time in order to allow an ordering clinician to review the results or in order to personally inform the patient of the results before a patient can electronically access such results (see also 85 FR 25842 specifying that such a practice does not qualify for the “Preventing Harm” Exception).

To further illustrate, it also would likely be considered an interference:

• where a delay in providing access, exchange, or use occurs after a patient logs in to a patient portal to access EHI that a health care provider has (including, for example, lab results) and such EHI is not available—for any period of time—through the portal.
• where a delay occurs in providing a patient’s EHI via an API to an app that the patient has authorized to receive their EHI."

What I am saying is that if you are declining to share notes with patients, the law lays out 8 exceptions, only a few of which are relevant to us as doctors. By clicking to not share them, you are asserting that they fall under these exceptions. I would not be surprised if some tedious mandatory training that was required sometime last year officially informed you of the standard (although obviously everyone just plows through these as quickly as possible). then, if it turns out later you can't justify doing it, it's not on the institution.

Right, except you VERY conveniently omitted what the question is on that website, and the response you're quoting:

Frequently Asked Questions | HealthIT.gov

www.healthit.gov

When would a delay in fulfilling a request for access, exchange, or use of EHI be considered an interference under the information blocking regulation?​

So read that again. What you are quoting is a response to a question that explicitly containts a "REQUEST" from the patient.

And since you read that website, here it is, right in the FAQ (not sure how you managed to miss this. It's literally the next question):

Are actors (for example, health care providers) expected to release test results to patients through a patient portal or application programming interface (API) as soon as the results are available to the ordering clinician?​

While the information blocking regulations do not require actors to proactively make electronic health information (EHI) available, once a request to access, exchange or use EHI is made actors must timely respond to the request (for example, from a patient for their test results). Delays or other unnecessary impediments could implicate the information blocking provisions.
In practice, this could mean a patient would be able to access EHI such as test results in parallel to the availability of the test results to the ordering clinician.
Please review the other questions under this heading for more information.

But whatever. Moving on.
Im going to stick with my institutions' policy. They hired real lawyers to figure all of this out.

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[Merovinge]

For the record, I appreciate you two going back and forth. At my last employer they understood it as per Clausewitz but I agree that large NYC programs probably are using pretty good lawyers (particularly ones attached to very prestigious law schools) and it's good to hear that there might be more sanity to this legislation.

 

[clausewitz2]

Person I was replying to was actively blocking notes individually, not automatically. Maybe this is the source of our disagreement. Actively opting to block is very clearly interference.

 

[G Sheb]

If you're on an inpatient unit, almost everyone has an elevated risk to "physically" harm themselves and others. Because unless it's a full voluntary unit, it's probably why they are there in the first place. And almost everyone has poor insight into their psychosis or mania or whatever.
The risk/benefit analysis here is pretty obvious.. Do not share the note if you think information about their psychosis or mania is going to increase the risk of harm to themselves or others, which is kind of almost always the case. Like, the risk is so much bigger than the purported benefit of patients reading their chart on a closed unit every day. The bar is not as high as some think it is for our population.
Which is why many institutions, including "top" ones do not automatically share units in psychiatry on inpatient units.
I don't think anyone would say here the doctor was acting 'unreasonably' if they routinely not share notes in cases like these.

However, again, CURES act is not synonymous with open notes. The Cures clearly establishes that 'proactive sharing' is not required. If you don't press that 'share' button, essentially you're not proactively sharing. You're not blocking information. Even the Open Notes campagin website makes that obvious that patient request to see their notes here is critical.

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In any case, you can tell how clueless these people on Open Notes are.
They have a section on 'recommendations' for mental health providers for 'challenging situations'.
This is how they describe these patients:
"the delusional patient"
"the borderline patient"
"the dishonest/manipulative patient"

They think it's OK to use this kind of terminology in papers and 'behind closed doors' but not in the medical record apparently.
Really, can't make that s*** up. LOL. Apparently they missed the irony that if their goal is to increase 'transparency', they are actually doing the opposite here. FTR, I think this language is inappropriate in the MR as well, whether patients have live access to it or not.

If it comes to a point where we don't write necessary medical terminology, such as not calling psychosis psychosis, paranoia "paranoia", delusions "delusions", then this is not a medical record any longer. If the task is to use the MR to do therapy then fine.. show me that it's worth my time. I still need to have a record where I can accurately write what's going on.

 

[smalltownpsych]

I write almost all of my notes with the thought that patients will read them. I also think about how they would look in court and have an awareness that people other than my patient will often see the record so I am very cautious about what I put in the record. Leads to short notes, so that’s a benefit.

 

[clausewitz2]

If you're on an inpatient unit, almost everyone has an elevated risk to "physically" harm themselves and others. Because unless it's a full voluntary unit, it's probably why they are there in the first place. And almost everyone has poor insight into their psychosis or mania or whatever.
The risk/benefit analysis here is pretty obvious.. Do not share the note if you think information about their psychosis or mania is going to increase the risk of harm to themselves or others, which is kind of almost always the case. Like, the risk is so much bigger than the purported benefit of patients reading their chart on a closed unit every day. The bar is not as high as some think it is for our population.
Which is why many institutions, including "top" ones do not automatically share units in psychiatry on inpatient units.
I don't think anyone would say here the doctor was acting 'unreasonably' if they routinely not share notes in cases like these.

However, again, CURES act is not synonymous with open notes. The Cures clearly establishes that 'proactive sharing' is not required. If you don't press that 'share' button, essentially you're not proactively sharing. You're not blocking information. Even the Open Notes campagin website makes that obvious that patient request to see their notes here is critical.

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In any case, you can tell how clueless these people on Open Notes are.
They have a section on 'recommendations' for mental health providers for 'challenging situations'.
This is how they describe these patients:
"the delusional patient"
"the borderline patient"
"the dishonest/manipulative patient"

They think it's OK to use this kind of terminology in papers and 'behind closed doors' but not in the medical record apparently.
Really, can't make that s*** up. LOL. Apparently they missed the irony that if their goal is to increase 'transparency', they are actually doing the opposite here. FTR, I think this language is inappropriate in the MR as well, whether patients have live access to it or not.

If it comes to a point where we don't write necessary medical terminology, such as not calling psychosis psychosis, paranoia "paranoia", delusions "delusions", then this is not a medical record any longer. If the task is to use the MR to do therapy then fine.. show me that it's worth my time. I still need to have a record where I can accurately write what's going on.

The previous poster talked about having to make a series of clicks to prevent sharing. This is prima facie interference.

I don't disagree with you at all about a rational risk benefit analysis of sharing inpatient notes. I think it is not a good idea most of the time during the hospitalization. Unfortunately the CURES Act does not ask us to weigh costs and benefits but puts the burden on us to articulate why the vote qualifies for the exception. The allowable exceptions are explicitly enumerated.

The FAQ you were quoting from also says that 'proactive' is not a concept in the regulations and those distinctions are not relevant. It simply considers whether an action you are taking is likely to materially interfere with timely access of a patient to their notes when they want it. Sure, they don't have to auto-populate. But unless your IT Department is able to make the case that it would be technically impossible, if the patient clicks a button requesting the note, it has to be provided without delay. You'll note that, based in that FAQ, the governmental body charged with regulating this definitely regards imposing a set and uniform blackout window to allow clinicians to review things first as likely constituting interference.


I am sure over at Columbia your lawyers have a legal theory as to why your department is allowed to do what it does. I would be very curious to know more about this legal theory and suspect it is a bit more complicated than 'it's fine, don't worry about it.' I trust their lawyers to do their best to insulate the institution. I am not so sure I would trust them to always be protecting you, since this act does limit healthcare providers themselves individually. Your faith in them having your interests at heart is really a question for you.

I 100% agree that medical records should be about transparency and conveying information. There would be advantages to secrecy. Still, it is prudent to not write anything in a note you would not be happy to say to the patient's face or read in a courtroom, so I don't. Makes everything much simpler. There are countries (Sweden for example) in which medical notes are regarded as property of the patient and they have had access for a long time; somehow, they continue to have a functioning mental health system.


FWIW our psychotherapy process notes are still protected.

 

[TheRightMedication]

I wonder if the reason for universal note blocking is not a legal theory but a statistical one. Perhaps blocking the proliferation of clinical notes is thought to reduce the probability of lawsuits to a degree that the risk is worth it?

 

[Merovinge]

I wonder if the reason for universal note blocking is not a legal theory but a statistical one. Perhaps blocking the proliferation of clinical notes is thought to reduce the probability of lawsuits to a degree that the risk is worth it?

I think the law is so new that there hasn't been much tested in court. Would be good to get an update when that happens.

 

[G Sheb]

I write almost all of my notes with the thought that patients will read them. I also think about how they would look in court and have an awareness that people other than my patient will often see the record so I am very cautious about what I put in the record. Leads to short notes, so that’s a benefit.

I do that as well.
I actually have changed literally nothing about how I write my notes.

You should not write disrespectful things in the chart or come off as an ass. Whether patients read it or not. Judgemental language never made any sense to include and usually was a reflection of the provider as much as the patient.

I have worked in an open note environment outpatient before the rule. 95% of patients don’t read their notes and don’t care. You get warned about one or two patients who read their notes and object to the slightest thing.

The problem here is with the cultural things that are being pushed with the implementation, that are completely nonsensical, make the medical record much less useful and doctors jobs a lot harder than they already are. Likely to reduce liability in case a mess up happens (and let’s face it, it is bound to if it didnt already occur). There’s a lot of nonsense coming off from the open notes advocates.